Provider Demographics
NPI:1487642161
Name:JACKSON, LYDIA LANE (PA C)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:LANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7028 CROSS BEND CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-2445
Mailing Address - Country:US
Mailing Address - Phone:334-213-6441
Mailing Address - Fax:
Practice Address - Street 1:215 PERRY HILL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-3725
Practice Address - Country:US
Practice Address - Phone:334-272-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant